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V. NOTARIZED STATEMENT$Fill in.Statements as applicable. <br /> V <br /> the representative of <br /> Applicarit Nathe <br /> ...... do hereby attest that the <br /> Business.Norrie of$§eirvice <br /> above named,00 <br /> ._001tvicle meets 411 the req -ompi- <br /> requirements of, and:that I agree C <br /> f Ch eblchai'0 <br /> with,all applicable pr.ovisibrn' <br /> 3 a6W4K Life Support and he. <br /> Services. <br /> MAN MR,-a I W01- <br /> the representative of <br /> Applicant Name <br /> do,fierahly atftsf-that, <br /> Business NaMq_9fSi9rvJce <br /> the above named-oorvice will provide continuous service on a 24. U' r, 7-day <br /> week basis. I do 4"by attest that the above named service meets:all the <br /> requirements for operation of an ambulance service in the State of Florida as <br /> provided:in Chapter 401, Part III, Florida Statutes, Chapter 64E-2 <br /> FloVida <br /> Administrative Code, and that I agree to comply with all the provisions of Chapter <br /> 364, Life Syp <br /> .portZervices. <br /> I further acknowledge that discrepancies discovered during the effective <br /> t <br /> period of the Certificate of Public Convenience and Necessity will subject <br /> this service and its authorized representatives to corrective action and <br /> penalty provided in the referenced authority and that to the best <br /> of my <br /> knowledge, all statements on this appll'cation are true and correct. <br /> APPLICANT SIRGMATURE DATE <br /> Before me personally appeared the said 64_,U4_ who says <br /> that he/she executed the above instrument of his/her own free will an1d,accord,with full <br /> knowledge of the purpose thereof. Sworn and subscribed in my presence this 23 day of <br /> 4to[ASt-- 2013. Z <br /> 0 My commission expires: <br /> ,Z,,!N&TA,RY PU LICP <br /> PW P& Notary Public State of Florida <br /> T } :, Barbara B Power <br /> My Commission EE 187480 <br /> ?of Expires 04/11/2016 <br /> UABethV3eth Casano EWCOPCINMENIEWAL PAMEn 1GOPcN Application rev.2013.doc <br /> 58 <br />